Report on

Integrated model of service delivery and community mobilization to ensure IFA

consumption during pregnancy according to national guideline in Satkhira,

Bangladesh

Case Study conducted under:

Improving Delivery and Uptake of Essential Nutrition Interventions through the Health and Food System and in the Community (IAHBI) Project, CARE Bangladesh.

Supported by UNICEF

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Report prepared by:

Md. Anowarul Arif Khan, Manager-Monitoring and evaluation,

CARE Bangladesh

Dr. Md. Sarbojit Anwar Kamal, Program Manager-Nutrition,

CARE Bangladesh

Md. Razibuzzaman Shah, Manager – Learning and Documentation,

CARE Bangladesh

Edited by:

Dr. Salahuddin Ahmed, National Nutrition Coordinator,

CARE Bangladesh

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Table of Contents

A. Background: ...............................................................................................................................5

B. Objective of the study ................................................................................................................7

C. Intervention of the project ..........................................................................................................7

D. Interventions used to improve effective IFA coverage: .................................................................9

E. Evaluation: ................................................................................................................................ 10

F. Discussion ................................................................................................................................ 12

G. Conclusion ................................................................................................................................ 13

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A. Background:

Prevalence of anaemia in children, pregnant and lactating women

Nutritional deficiencies are the most common causes for anaemia. Iron deficiency anaemia is a major

contributor to the global burden of disease (WHO, 2008). In addition to iron, other nutritional

deficiencies (e.g., folate, vitamin B-12) can cause anaemia. Pregnant women with a haemoglobin level

less than 11g/dl and non-pregnant women with a level less than 12g/dl are considered anaemic (WHO,

2001).

During the past three decades a number of studies including four national nutrition surveys (1962/64;

1975/76; 1981/82 and 1995/96) have been carried out to investigate the prevalence of anaemia among

different population groups in Bangladesh, and those have demonstrated that anaemia is a significant

public health problem. Among the rural population, the prevalence of anaemia is 43% in adolescent

girls, 45% in non-pregnant women and 49% in pregnant women [Food Security Nutritional Surveillance

Project 2013, BRAC Institute of Global Health (BIGH)]. The data on the aetiology of anaemia reveal that

iron deficiency may be a substantial cause of anaemia in the Bangladeshi population. Other dietary

factors in addition to parasitic infestations may also contribute the high prevalence of anaemia. Low

haemoglobin level was highly prevalent both in pregnant and lactating women (Table 1)

Table 1: The mean haemoglobin concentrations (g/dl) in pregnant and lactating women in three

districts of IAHBI project

Subjects

Overall Location Districts

Satkhira

mean (SD)

Khulna

mean (SD)

Barisal

mean (SD)

Pregnant women (n=99) 10.4 (1.3) 10.3 (1.4) 10.8 (1.2) 9.6 (1.4)

Lactating women (n=272) 11.4 (1.3) 11.4 (1.2) 11.6 (1.4) 11.0 (1.7)

Source: Baseline Survey Report on “Integrated Agriculture and Health Based Interventions for Improved Food and Nutrition Security in selected districts of Southern Bangladesh” by Food Security Nutritional Surveillance project, BRAC Institute of Global Health (BIGH), December 2013

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Figure 01: Prevalence of anaemia among pregnant and lactating women by district

Source: Baseline Survey Report on “Integrated Agriculture and Health Based Interventions for Improved Food and

Nutrition Security in selected districts of Southern Bangladesh” by Food Security Nutritional Surveillance project,

BRAC Institute of Global Health (BIGH), December 2013

The overall anaemia prevalence was high in both pregnant and lactating women. The prevalence of

Anaemia among pregnant women was 68.4% in Satkhira, 50% in Khulna and 81.8% in Barisal district. On

the other hand, the prevalence of aneamia among lactating women of the same district was 68.7%,

61.3% and 70% respectively. The prevalence was highest in Barisal and lowest in Khulna district both for

pregnant and lactating women. The overall anaemia prevalence was also very high in baseline among

lactating women (66.0%) compared with earlier nationally representative survey findings (NSP 2001,

33.0%; NMSS 2013, 26.0%).

The Improving Delivery and Uptake of Essential Nutrition Interventions through the Health and Food

System and in the Community (IAHBI) project of CARE Bangladesh falls within a larger joint project

between FAO and UNICEF, funded by USAID to improve food and nutrition security with special focus on

pregnant and lactating woman, adolescent girls and under 5 children of Assasuni and Shyamnagar

upazilas of Satkhira and Muladi upazila of Barisal district in southern Bangladesh from June, 2013 to

May, 2015. A baseline survey was conducted in 2013 by FSNSP project, BRAC Institute of Global Health,

BRAC University to understand the nutritional gaps to ensure better agricultural output, dietary diversity

and nutritional status of women and children in southern districts.

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Before initiating interventions on services delivery and community mobilization an explorative study was

executed on April, 2014 to find out the status of consumption of IFA tablet by pregnant women

according to national guideline in selected 03 unions of two upazilas (Assasuni and Shyamnagar) of

Satkhira. After project interventions another survey was conducted on October, 2014 at same location

with women with having child aged less than 6 months to find out the effect of the interventions. Here

in this report it was tried to find out the results and effect of these interventions.

B. Objective of the study

The key objective of the study is to develop an integrated model of service delivery and community

mobilization to ensure IFA supplementation during pregnancy according to national guideline.

Specific objective is:

To ensure at least 100 IFA tablet consumption by pregnant women in selected three unions

of two upazilas (Assasuni and Shyamnagar), Satkhira following national guideline of IFA

supplementation

C. Intervention of the project

The current government policy to prevent and control anemia includes Iron Folic Acid (IFA) tablet

supplementation to pregnant and lactating women, and adolescent girls and unmarried women through

service delivery points [Family Welfare Center (FWC), Community Clinic (CC), Upazilla Health Complex

(UHC), Satellite clinic etc] through frontline workers e.g. Family Welfare Assistant (FWA).

The national recommendation of IFA is as below:

Table 2: National guideline for supplementing IFA tablet

Target Group Dose Duration

Adolescent girls (13-19 years) and not pregnant women

Elemental iron 60 mg + folic acid 400 µg Per week- 02 tablet

03 month continue Next 03 month stop Again next 03 month - continue

Pregnant women Elemental iron 60 mg + folic acid 400 µg Per day- 01 tablet

Throughout pregnancy

Lactating women Elemental iron 60 mg + folic acid 400 µg

After delivery for 03 months

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Social Map of Kochua CC in Assashuni Upazila of Satkhira

district

Photo Credit: Mr. Ataur Rahman,

Per day- 01 tablet

Children (06-24 months) Elemental iron 12.5 mg + folic acid 50 µg Per day- 01 time Or, Micro Nutrient Powder (MNP-05 ingredients) Per day- 01 sachet with food

02 month continue Next 04 month stop Again next 02 month - continue

Children (02-05 years) Elemental iron 20- 30 mg + folic acid 200 µg Per week- 01 time

03 month continue Next 03 month stop Again next 03 month - continue

Children (05-12 years) Elemental iron 45 mg + folic acid 400 µg Per week- 01 time

03 month continue Next 03 month stop Again next 03 month - continue

Reference: IPHN-NNS 2012

UNICEF has been supporting “Integrated Agriculture and Health

Based Intervention (IAHBI)” Project in the Southern part of

Bangladesh (Satkhira and Barisal) since 2013. The objective of the

project is, “To improve the delivery, monitoring and uptake of

essential nutrition interventions and practices through the local

health and food system and in the community”. The focus of the

project is to mainstreaming nutrition through existing GoB health

facilities and Health System strengthening. IFA supplementation for

pregnant and lactating women and adolescent girls is one of the

major components of Direct Nutrition Intervention (DNI). IFA tablet

is being dispensed to the target group through all GoB health and

family planning centers – FWC, CC, satellite clinic and through FWA

during bi-monthly home visit. As the project has main focus on GoB

health system strengthening and DNI mainstreaming, so the project continuously engages and provides

effort to ensure that all health and family planning service providers are adequately capacitated on

planning, implementing and monitoring of DNI, nutrition interventions mapping and mainstreamed

those into different health service platforms (UHC, FWC, CC). Also the project emphasized and ensured

that all health and family planning authorities including managers and partners are adequately oriented

on nutrition activities and have the capacity to monitor and supervise nutrition activities and providers.

9 | P a g e Participants of the CG are discussing about the

progress of IFA consumption during their meeting

After a few months of implementing intervention, project conducted bottleneck analysis to find out gaps

as to why pregnant women were not consuming at least 100 IFA tablets during pregnancy. The key

finding was women were not getting IFA tables. Then the CARE Bangladesh project team developed a

model of integrated intervention at facility and community level to improve IFA consumption during

pregnancy. This integrated intervention was implemented at three unions - two in Assasuni and one in

Shyamnagar upazila of Satkhira district.

D. Interventions (started on May, 2015 and still continuing) used to improve effective

IFA coverage:

Below activities were taken:

Ensuring registration of all pregnant women at CC and in FWA register

This registration was validated by GoB frontline supervisors during household and facility visits

The service providers [Community Health Care Provider (CHCP), Family Welfare Assistant (FWA),

Family Welfare Visitor (FWV) ] provided adequate number of IFA to all pregnant women using the

register and made counseling on IFA including its benefits, side-effects and potential solution of

side-effect

Supervisors and FWA follow up on consumption during household visits

Community Group (CG) and Community Support Group (CSG) follow up all pregnant women to

ensure referral and consumption of IFA using CSG register of pregnant women and social map

Building awareness regarding the importance of consumption of IFA tablets at the community by

Adolescent Girls Group (AGG), Community Group (CG), Community Support Group (CSG), Mother

Support Group (MSG) and religious leaders

Ensuring supplies of IFA tablets and maintain communication with Upazilla Health & Family Planning

Officer (UH&FPO) and Upazilla Family Planning Officer (UFPO).

AGG are taking preparation for their meeting about

building awareness of consuming IFA

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Intervention delivery process:

E. Evaluation:

E.1. Indicator details of the study:

Determinants Indicator

Availability % of pregnant women for whom sufficient quantities of IFA tablets have been supplied

Access % of pregnant women who have access within 30 minutes to Ante Natal Care (ANC) services (from FWC or CC) providing IFA supplementation

Utilization % of pregnant women who received IFA tablets from first ANC visit

Adequate coverage

% of pregnant women who received at least 100 IFA tablets during last pregnancy

Effective coverage

% of women who consumed at least 100 IFA tablets during last pregnancy

Registration

of all

pregnant

women

Capacity

building of

health

providers

Pregnant

women

received and

consumed IFA

consume IFA

Efficient

planning and

monitoring

Promoting

behavior change

using CG, CSG,

AGG, MSG Follow-up by

Supervisors, CG

and CSG

Strengthening

supply chain

through accurate

forecasting

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E.2. Data collection:

Data have been collected on October, 2014 to evaluate intervention impact. Lot Quality Assurance

Sampling (LQAS) method was used for this purpose. Randomly selected 66 lactating women were

interviewed with semi-structured questionnaire.

Table 3: Sample size for data collection

Name of Upazilla Name of Union # of lactating women interviewed

Assasuni Shreeula 19

Assasuni Bordal 19

Syamnagar Ramjannagar 28

Total 66

Community Facilitator (CF) of IAHBI project collected data using random sampling method from a

lactating women list under close supervision of Upazilla GoB Health Managers.

E.3. Analysis

Data tabulation sheet (Excel) is used for quantitative data analysis, which is a part of LQAS package.

Before entering data into data tabulation sheet they are cross checked. Then calculation and analysis of

data yields findings of the survey.

E.4. Results

The study explored the IFA consumptions status of those selected unions of two study upazilas. Status of

IFA consumptions after intervention is shown in the below Tables (Table 4 and Table 5). Table 4 presents

the situation of Assasuni upazila which illustrates that the availability, accessibility and utilization of the

IFA are 100%, but adequate coverage and effective coverage both are 84% among lactating mother

during their last pregnancy period. On the other hand at Syamnagar upazila, the availability,

accessibility, utilization and adequate coverage of IFA all are 100%, but effective coverage is 93% (Table

5). The details of the results are as below:

Table 4: IFA supplementation status of Assasuni upazilla

Name of Upazilla

Name of Union Availability Accessibility Utilization Adequate coverage

Effective coverage

Assasuni Shreeula 100% 100% 100% 89% 89%

Bordal 100% 100% 100% 79% 79%

Total 100% 100% 100% 84% 84%

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Table 5: IFA status of Syamnagar upazilla

Name of Upazilla

Name of Union Availability Accessibility Utilization Adequate coverage

Effective coverage

Syamnagar Ramjannagar 100% 100% 100% 100% 93%

F. Discussion

After the project intervention, the IFA consumption status for both Assasuni and Syamnagar upazilas

has significantly improved. The Figure 2 shows the difference between two different periods of IFA

consumption at Assasuni upazila. A bottleneck study was conducted in April, 2014 which was

compared to the data collected after implementation of new intervention in October, 2014. It was

found that, the availability of IFA was 100% both on April, 2014 and October, 2014. But accessibility

increased from 94% to 100%, utilization increased from 42% to 100%, adequate coverage increased

from 42% to 84% and effective coverage of IFA increased from 35% to 84% during this time period.

Figure 02: IFA consumption status of Assasuni upazilla on pre and post intervention

Figure 3 compares the situation of IFA consumption for two different time periods of Syamnagar upazila

where data comparison was done after project intervention in October, 2014 to the data collected in

April, 2014. It is found that, the availability of IFA in Syamnagar upazila was 100% for both point of time,

accessibility increased from 90% to 100%, utilization increased from 86% to 100%, adequate coverage

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For more information, please contact:

CARE Bangladesh

Pragati Insurance Bhaban , 9th to 13th Floor, 20-21 Kawran Bazar,

Dhaka-1000, Bangladesh

Phone: 88-02-9112315, Ex 347, Fax: + (880) 2 9118347,

E-mail: info@bd.care.org, Website: www.carebangladesh.org

increased from 28% to 100% and effective coverage increased from 24% to 93%. Effective coverage of

IFA increased significantly in all three unions of two upazila.

Figure 03: IFA consumption status of Syamnagar upazilla of before and after project intervention

G. Conclusion Consumption of at least 100 IFA during pregnancy is feasible through existing GOB health system,

and involving existing community support system including CG, CSG, Adolescent Girls Group, Mother

Support Group. This model can be scaled up in other low performing areas whit minimum resource

mobilization.